Clinical psychology comment

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More work less therapy

October 11, 2004

Peter Kinderman will, over coming months, be writing a column for psychminded.co.uk. Here he argues that if clinical psychologists really want to assist clients they should focus on helping them find employment as much as providing cognitive behavioural therapy.

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A rather random search of Google (an unusual scientific strategy, but relevant here) reveals that cognitive behavioural therapy is a successful treatment for: depression; anxiety, stress, panic disorder, obsessive-compulsive disorder, agoraphobia and other phobias; health problems such as headaches, bulimia, rheumatic pain and smoking cessation; childhood difficulties such as bedwetting and oppositional behaviour; and marital distress.

One practitioner, perhaps motivated by a desire to drum up business, suggested that CBT is particularly well suited to address multicultural, alternative lifestyle, and religious issues. This optimism is justified by more scientific analyses of the therapeutic efficacy of CBT (Butler & Beck, 2000).

We all know what CBT is. The basis of cognitive therapy is the idea that psychological difficulties arise from the way we interpret the world and what happens to us. "Core beliefs" - beliefs about ourselves, other people and the social world that are developed during childhood and adolescence - generate negative automatic thoughts that in turn create psychological distress.

Cognitive therapy offers a range of techniques for dealing with negative thoughts and a range of techniques to help people understand their core beliefs and test their appropriateness.

CBT, therefore, is based on the principle that the mechanisms driving mental disorder (or rather, the list of issues for which CBT is believed to be effective) are mediated by cognition. This principle is valid, but perhaps incomplete. Not all the psychological mechanisms or processes involved in mental disorder (and certainly those involved in such things as rheumatic pain) are cognitive.

'A'-level psychology textbooks tend to make reference to a number of broad psychological models. Psychologists have described themselves as 'biological psychologists', 'psychodynamic psychologists', 'humanist psychologists', 'behavioural psychologists' and 'cognitive psychologists'.

In the context of such a variety of psychological models, psychologists have repeatedly stressed the importance of clinical case formulations (British Psychological Society Division of Clinical Psychology, 2000; 2001).

Psychological case formulations are, we maintain, complex and may comprise a number of provisional hypotheses, based on a large variety of psychological theories, each drawing on scientific research.

For many people, however, the typical formulation differs from the examples given in Beck's seminal 1979 textbook. Trainee clinical psychologists, in particular, seem to specialise in producing case reports with formulations consisting of dysfunctional attitudes, negative automatic thoughts and the consequent triad of feelings, thoughts and behaviours.

This seems rather inadequate. It does not strike me as a conceptually complete picture. Especially when we return to the broader history of psychology. Where, in such a picture dominated by negative automatic thoughts and core dysfunctional beliefs, are the hypotheses making reference to the psychological traditions referred to above?

In my opinion we - that is, applied psychologists - would be foolish and unscientific if we ignored cognitions and CBT. First, the role of cognitive processes in guiding and shaping behaviour is scientifically undeniable (Dalgleish & Power,1999). Second, as Butler and Beck (2000) point out, CBT works.

But I think psychologists should realise that cognitive processes, and especially overt, declarative, conscious cognitive processes are not the only mediating psychological mechanisms in mental distress, and that negative automatic thoughts, core dysfunctional beliefs and maladaptive schemas are not the sum total of cognitive psychology.

And, in particular, we should be aware that things other than therapy can be hugely beneficial. Work can provide income, but also psychological (even cognitive) benefits, such as social identity, status, social contacts, support, activity and community involvement and a sense of personal achievement.

Employment helps maintain good mental health and in turn promotes recovery (Boardman, Grove, Perkins and Shepherd, 2003). However, rates of employment remain low (typically lower than 10% employed) for people with long term mental health problems (Huxley and Thornicroft, 2003).

In addition to the rather prosaic idea that CBT might have some knock-on consequences for employment and social functioning, psychologists could play a range of more interesting, imaginative and significant roles.

The government's recent social exclusion unit report into employment and mental health (2004), and the contribution of clinical psychologists to that report, outlined some of the possibilities.

Community psychology has a long tradition of helping to empower communities to overcome social and psychological difficulties themselves. Even the more conventional self-help groups (which offer an alternative to a medicalised diagnose-treat approach) can be beneficial.

Psychologists could become more actively involved in health promotion or, in this context, help minimise the impact of mental ill health on employment.

Perhaps we should focus on consultative work, offering expertise and skills to agencies that help match job opportunities to people who have experienced mental health problems (see for instance Network Employment at Merseycare NHS Trust: www.merseycare.nhs.uk/content-661), or conduct educational work with government employment agencies, large employers and chambers of commerce.

Psychologists should (and do) engage with policy-makers and legislators in discussions concerning employment and disability legislation. We should (and do) consult on a variety of national policies regarding invalidity and other benefits in order to support proper contractual arrangements and employment practices (including such things as a graded return to work) to protect people who may experience recurrent mental health problems.

But at present, such initiatives are rare. Few psychologists are as active in promoting employment and social inclusion as they are in marketing CBT. Myself, regrettably, included.

References:
* Beck, A.T., Rush, A.J., Shaw, B.F. & Emery, G. (1979). Cognitive therapy of depression. NewYork: Guildford Press.

* Boardman, J., Grove, B., Perkins, R. & Shepherd, G. (2003) Work and employment for people with psychiatric disabilities. British Journal of Psychiatry. 182: 467-468.

* Butler, A. C., & Beck, J. S. (2000). Cognitive therapy outcomes: A review of meta-analyses. Journal of the Norwegian Psychological Association, 37, 1-9.

* British Psychological Society Division of Clinical Psychology (2000) Understanding Mental Illness and Psychotic Experiences: A Report by the British Psychological Society Division of Clinical Psychology. Leicester: British Psychological Society.

* British Psychological Society Division of Clinical Psychology. (2001) The core purpose and philosophy of the profession. Leicester: British Psychological Society Division of Clinical Psychology.

* Dalgleish, T. & Power M. [Eds.] (1999) Handbook of cognition and emotion, 2nd Ed. London: Wiley.

* Huxley, P. & Thornicroft, G. (2003). Social inclusion, social quality and mental illness. British Journal of Psychiatry. 182: 289-290.

* Peter Kinderman is honourary consultant clinical psychologist for Merseycare NHS Trust, a reader in clinical psychology at the University of Liverpool and chair of the British Psychological Society's division of clinical psychology

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'Talk and listen - and save us from ridiculous psycho-theisms like CBT'

Comment from: Phil Barker, professor of health science, Trinity College, Dublin, Ireland.
Date: October 31, 2004

"My first experience of (what was then known as ) cognitive therapy, was over 25 years ago, when in my doctoral study I explored the utilty of cognitive therapy with women with a diagosis of manic depression.

"I was not suprised to find that 'it worked'. I am sure that, with hindsight, anything that I had done - with complete human commitment, enthusiasm, and optimism - would have 'worked', in terms of helping relieve some of the emotional distress of those women.

"Twenty five years later I make no pretence at wisdom, but I flinch every time I hear and read psychologists talking and writing glibly and foolishly about how things (like CBT) 'work', especially when they throw in casual references to their 'scientific' frame of mind.

"The human reality - as even a causal search of the psychotherapy outcome literature will reveal - is that 'everything works'. The question is, how does 'it' work, for ''whom' and to what 'particular purpose'?

"At the risk of sounding like a 'lapsed practitioner' it seems clear that CBT is a fine example of one way of helping some people to understand and manage their emotional and behavioural problems. May the gods preserve us from psychologists who think that this explains anything more.

"If we want to know what is 'going on' within a person and how we might help them understand this better, we simply need to talk to them and listen to them, unfettered by ridiculous psycho-theisms like CBT."

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